The emergency clinician must be aware-that the absence of radiological abnormality reduces the chances of spinal injury but does not exclude it. About 8% of patients have injuries to the cervical spine in more than one place and 15% of patients with cervical injury also have a thoracolumbar injury Make sure all seven cervical vertebrae and the C7/T1 junction are visible. The spinous processes may not be clear. Ifyou suspect an injury obtain a further view.Physiological subluxation of the bodies of C2 on C3 (seen in a quarter of cases) and C3 on C4 (seen in 15% of cases) occurs up to 8 years of age. However, the posterior spinal line is maintained.Artefactual shadows can sometimes cause confusion. In the open mouth view the vertical cleft between the upper two incisor teeth may be mistaken for a vertical fracture ofthe peg. Do not forget to examine the soft tissue shadows; these may be the only clues to an underlying fracture. SummaryAdequacy and quality Ensure that the vertebrae C1-C7 and the C7/T1 junction are visible Alignment Assess the contours of the cervical spine and appendages Bones Check each vertebra for shape, height, and fractures Check the shape of the odontoid peg Check spinal canal size

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The purpose of this article is to use the ideas of path dependency to understand why policies implemented by governments for health care in England were and are suboptimal in terms of the control of total costs, the equitable distribution of hospital services, and efficiency in delivery. We do this by relating the economic logic of achieving these objectives to the political logic of a state-hierarchical system in which ministers are accountable for the effects of policies and doctors largely decide the supply and demand of health care. The initial policy path of the National Health Service (NHS) controlled costs but lacked systems to achieve equity and efficiency in the funding of hospitals. Policies were introduced to achieve equity, but not efficiency, in the 1970s. The Thatcher government sought efficiency through a budgetary squeeze in the 1980s, which culminated in the NHS funding crisis of 1987 - 1988. The result was the policies of the NHS internal market, which promised efficiency by introducing a purchaser-provider split and a system of provider competition in which money would follow the patient. These promises justified an injection of extra funds for three years, but only a pallid model of the internal market was implemented. The Blair government abandoned the rhetoric of competition but maintained the purchaser-provider split and continued to constrain total NHS costs, which resulted in the funding crisis of 1998 - 1999. Current policies are to substantially increase spending on health care and reintroduce a system of provider competition in which money will follow the patient.

Productive methods for involving consumers require appropriate skills, resources and time to develop and follow appropriate working practices. The more that consumers are involved in determining how this is to be done, the more research programmes will learn from consumers and about how to work with them. Further success might be expected if research programmes embarking on collaborations approach well-networked consumers and provide them with information, resources and support to empower them in key roles for consulting their peers and prioritising topics. To be worthwhile, consultations should engage consumer groups directly and repeatedly in facilitated debate; when discussing health services research, more resources and time are required if consumers are drawn from groups whose main focus of interest is not health. These barriers can largely be overcome with good leadership, purposeful outreach to consumers, investing time and effort in good communication, training and support and thereby building good working relationships and building on experience. Organised consumer groups capable of identifying research priorities also need to find ways of introducing their ideas into research programmes. Further research is suggested to develop and evaluate different training methods, information and education and other support for consumers and those wishing to involve them; to address the barriers to consumers' ideas influencing research agendas; and to carry out prospective comparative studies of different methods for involving consumers. Research about collective decision-making would also be further advanced by addressing the processes and outcomes of consensus development that involves consumers.

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